Switch On Your HIV Smarts.

Gay Men’s Health: A Q&A with Dr. Ron Stall

Today we introduce BETA’s newest column: “Gay Men’s Health.” Look to this quarterly column for health news, perspectives and expert opinions, and whole-person wellness strategies specifically geared for gay and bisexual guys and other men who have sex with men. Is there a topic you’d like to see covered? Leave a comment and let us know!

Our new “Gay Men’s Health” column launches with an illuminating and lively Q&A with a pioneering researcher who is turning the gay men’s HIV-prevention conversation on its head. Dr. Ron Stall, Professor of Public Health at the University of Pittsburgh, wants prevention efforts to leverage gay men’s strengths rather than focus solely on issues that put them at risk.

Dr. Ron Stall (photo: San Francisco AIDS Foundation)

Stall’s work with the Urban Men’s Health Study uncovered “syndemics” among gay men: overlapping psychosocial health issues that have an additive effect. Of the health problems that overburden gay men, Stall observes, HIV/AIDS may only be the most recognized; according to his research, the disproportionately high HIV prevalence among men who have sex with men (MSM) goes hand in hand with documented higher rates of substance use, clinical depression, partner violence, and childhood sexual abuse.

At the same time, however, research by Stall and his colleagues uncovered “resiliencies” that help protect gay men’s health, such as the capacity to resolve substance use problems over time and the ability to remain HIV negative despite having experienced syndemic conditions that would ordinarily increase their HIV risk.

Tapping into these resiliencies, says Stall, could inform HIV-prevention and wellness interventions that truly resonate with gay men and help them keep themselves and their partners healthy and happy.

. . .

BETA: At a session at AIDS 2012, you commented that “scientists are just obsessed with the area between the knee and navel when it comes to gay men.” Why do you think that is?

Dr. Ron Stall: If you actually look at the literature on gay men’s health, it’s just overwhelmingly about sexual health and [sexually transmitted infections]. That’s certainly an important piece of health disparities among gay men, and certainly some of the most famous health disparities among gay men—the trump card, of course, being HIV—are, in fact, sexually transmitted diseases. But our point is that gay men have lots of moving parts—some of them not, you know, our genitals.

These other parts—our emotions and our mental functioning—also can result in serious health problems if not well taken care of. We believe these kinds of problems have been understudied among MSM [men who have sex with men] and, in fact, have a great deal to do with explaining the problems and distribution of sexually transmitted diseases, as well. We think that this overarching obsession with the area between the knee and the navel is not serving us very well, in terms of preventing and addressing health disparities that exist among gay men.

BETA: Something that surprised me when reading your work is how many of these things seem to begin far earlier than you might expect if you’re focusing on adult health.

Dr. Stall: Our group here at the University of Pittsburgh has done a whole series of meta-analyses to show that some of the most serious of the health disparities—not only HIV, where the rates of HIV infection among gay youth are far greater than among their heterosexual counterparts—but also violence victimization, depression, suicidality, substance abuse epidemics, and so on are far higher among sexual minorities than they are in their heterosexual counterparts.

So something really horrible is happening to our gay youth before they achieve adulthood. And this sets up gay men, in particular, to enter their adult years already with significant health disparities beyond those that are found in their heterosexual counterparts.

BETA: This is a timely conversation given that even mainstream media is turning attention to bullying of LGBT youth. It sounds like this is evidence that bullying isn’t just something you “get over” after high school—that it can affect you lifelong.

Dr. Stall: Right. What we’ve been doing with our analyses is looking at the extent to which a whole series of these psychosocial health problems—particularly ongoing violence victimization, depression, substance abuse, and sexual compulsion—they’re intertwining and making each other worse. They’re interconnecting epidemics that, in turn, are driving HIV risk taking.

This is called a “syndemic” or a “synergistic epidemic.” We’ve been able to show (and this analysis has been reproduced now about six or seven times) that there’s a syndemic operating among gay men that, in turn, is driving HIV risk and even HIV seroconversion.

What does this have to do with bullying? What we’ve been able to also show is that a syndemic is already well in place among gay teenagers, and what appears to be a major force, in terms of syndemic production, is not only violence victimization but sexual shaming and marginalization at a very, very early age.

So if you raise a kid with a lot of violence victimization, and tell them that their life on this earth is a waste of oxygen, you’re not going to raise a healthy adult. And that’s what we do systematically to our gay kids over and over again, particularly in our schools and on our playgrounds. They’re fair game for bullying and violence victimization, with very few people there to protect them.

When this happens to me as an adult, I’m able to say, “Hey, pal, that’s Dr. Faggot to you!” And I’ve got a community behind me. I can call lawyers. I can call cops. I know how to defend myself. But when this happens to a 14-year-old who does not have the skill set, who does not understand what’s happening to him, who feels like he can’t tell his parents he’s getting beaten up because there’s a dual admission—he’s getting beaten up, and he’s getting beaten up for being gay—there are very few places for this young man to go where he can be safe and protected and where he’s not going to be a victim of this onslaught. Which means that it’s much more difficult for somebody like that to come of age, in a way. He’s not going to come into his adult years without bearing the scars of victimizations.

The other pathway that happens, we believe, is that a lot of gay kids manage to get through their teenage years without being identified by the bullies or being made a public example by these bullies. But the kids who “pass” also have to spend their teenage years walking a tightrope of being terrified and being identified, because then there’s no difference between them and the kid who’s getting beaten up all the time.

And so that self-censoring—always walking the tightrope, never being able to disclose your sexual orientation, never being able to talk about what’s going on—means that you get through your teenage years not really able to do a lot of the things that most teenagers are able to do as they’re coming of age. How can you join a clique if you’re always hiding who you really are? How can you make best friends? How can you fall in love if you can’t admit who you want to fall in love with?

There are basic skill sets that most people are able to use as teenagers. A lot of gay men go through their teenage years having to delay those experiences and put them off and spend a lot of time self-censoring and hiding, which we think is the beginning of internalized homophobia, which in turn gives rise to many of these syndemic conditions.

BETA: Are those young people at higher risk for HIV later in life, simply because they don’t yet have the words or the skills to negotiate around safer sex when they eventually do begin forming those relationships?

Dr. Stall: What we think is going on is that young men who are coming into their adult years already depressed, already at high risk for substance abuse, whose early socialization is to expect a lot of violence victimization—those are young men who are very vulnerable for high-risk sexual expression. And that’s a set-up for HIV infection.

BETA: Your research also highlights gay men’s strengths.

Dr. Stall: Right. We have some papers coming out to show the effects of early violence victimization on syndemic production among gay men, and very strong findings. But another thing that we noticed as we were doing our analysis was that there were huge amounts of evidence for resiliencies among gay men, and that they’re actually very common.

Even though there are many men who are raised with these kinds of experiences, over time they’re able to recover and exhibit huge strengths that I think have also been understudied among gay men. So it’s not just the knee-and-the-navel problem; it’s that we’re always looking for problems with gay men.

What we’ve understudied over and over again with gay men and in our responses to the AIDS epidemic has been the issue of documenting resiliencies in the community that could be used as the basis of intervention design.

So here’s an example of one. Because we got interested in resiliencies and were looking for them, one of the members of our group, Dr. Amy Herrick, pointed out that in our study, we actually were asking guys to chart their sense of internalized homophobia across the life course. And what we were able to show is that, as anybody who’s been around the gay community can tell you, over and across a life course gay men start out with a great deal of internalized homophobia as a group, but over time that goes away. So that what we were able to show is that there’s this kind of naturally occurring resiliency that happens among gay men across a life course. You want people to lose their internalized homophobia, and gay men are doing that on their own quite well, thank you very much.

BETA: Did that study detect any correlation between overcoming internalized homophobia and building social networks, feeling like they’re part of a community?

Dr. Stall: That’s probably a major driver in terms of resolving internalized homophobia. However, another thing that was really cool is that we were able to show there are some men who do better at resolving internalized homophobia than others across the life course—and lo and behold, the guys who did the best in terms of resolving internalized homophobia were also the men who were most protected against syndemics.

So what this suggests is that you can start to do HIV interventions with the goal of helping men resolve their internalized homophobia.

Now let me ask you this—if you were a gay man, which HIV intervention would you rather go to: a workshop showing you how to use a condom, or a workshop with other gay men learning how to do things to be more proud about yourself, and to have fun and have pride in being an out gay man?

When you start to do interventions based on resiliencies, you start to think of things that would be a lot more inviting than hammering people about health that happens to be about the area between the knee and the navel.

BETA: That gets back to something else that was a big theme during at AIDS 2012: how creating safe and welcoming spaces is absolutely critical to getting people to the places where they can access prevention services or medical care.

Dr. Stall: Another big thing that happened at the conference was talking about the “treatment cascade,” where there are a lot of people who are falling in the cracks when it comes to HIV prevention and treatment. But there are a lot of folks who do successfully navigate these things and who are exhibiting huge resiliency.

Now, the usual way of setting up these interventions is to look at the ways in which people fall in the cracks. Our response to that would be, “How about if we look at the folks who are successfully navigating these systems, getting into care, and achieving undetectable viral load? How about if we focus on the successes, and then learn the lessons, the strategies that the guys who are successful in navigating these complex systems are using, and see if those kinds of lessons could be exported to the guys who are having a bit more trouble at these systems?”

You see how the logic changes when you go with the resiliency? Looking for practical lessons learned from strong and effective gay men and seeing if those kinds of lessons can be exported or diffused to other guys who are having a bit more trouble.

BETA: You observed earlier that homophobia and violence against LGBT youth are setting them up for health disparities and HIV risk as they enter adulthood. What advice would you give to those young people?

Dr. Stall: Well, there are a lot of resources out there now that didn’t use to exist. There are things like It Gets Better, there’s the Trevor Project for young people who are really in crisis.

There’s also a much bigger recognition that there are sexual minority youth out there, and that it’s not a sickness or something to be afraid of—it’s just a difference. And there are a lot more adults out there who are willing to lend a hand.

That said, there’s a lot more surveillance of these kids, and in some ways I think teenagers now have it harder than when I was a teenager, because in my day it was kind of unthinkable that a kid would turn out to be gay. Now it’s very much on everybody’s radar. And so I think it’s kind of a double-edged sword—there are more resources out there, but the surveillance is higher.

I think my advice to young people would be the same advice that I think [It Gets Better founder] Dan Savage gives. Being a 16-year-old gay boy is not easy; being gay isn’t easy. Being a 16-year-old gay man may really be the hardest time of it all. It does get better.

The advice that I would give to that young man would be, “We know it’s tough now, you’re right, it is tough. So focus on the adult that you want to be. Think about the 25-year-old man that you want to be. Who do you want to be? Where do you want to live? What kinds of friends do you want to have? What kind of a relationship do you want to have? Do you want to have kids? You can have kids if you want. Do you want to be a professional? You can be a professional if you want. Do you want to go to college? You can do that if you want. There are no barriers out there now. You can be a thriving adult who can fall in love, who can make a family, who can be successful, who can be an extremely happy person. But the choices that you make as a 16-year-old are going to have a lot to do with whether that 25-year-old fantasy of your best self gets created. There are many, many things that you can do, even as a 16-year-old, to make that 25-year-old thriving adult a reality.”

While youth is very big piece of it, the things that happen with adults are also important. And as a consequence, we need to do a better job building community and making it safe for gay men to belong. That kind of community building probably has huge public health implications that we’ve never been able to measure but are very, very big deals in terms of keeping gay men safe.